The term “lymphatic malformations” refers to a broad range of lymphatic system defects (aplasia, hypoplasia and hyperplasia of lymphatic channels and nodes (1), or localized unifocal lesions consisting of dilated lymphatic channels filled with lymph but disconnected from the rest of the lymphatic system (2)). In many cases these defects cause lymphedema (abnormal accumulation of interstitial fluid due to inefficient uptake and reduced lymphatic flow); in other cases lymphatic malformations are not associated with lymphedema. In the past, lymphatic malformations (LMs) and primary lymphedema were considered two different entities, however according to the Hamburg classification, primary lymphedema is a clinical manifestation of LMs appearing in later stages of lymphangiogenesis (truncular LMs) (1), whereas extratruncular lesions, known as cystic/cavernous lymphangiomas, develop during earlier stages of lymphangiogenesis (1). The prevalence of truncular and extratruncular LMs is 1-5/10,000.
In the first step of diagnosis, clinical history and physical examination (3) of patients with LMs should reveal whether the malformation is truncular, extratruncular or syndromic, and if the disorder is inherited or sporadic (4). Lymphoscintigraphy has proved extremely useful for depicting specific lymphatic abnormalities (3). Radioactive colloid is injected into the toe web spaces and uptake by the ilioinguinal nodes is measured at intervals. Lymphoscintigraphy is performed to determine if there is a lack of uptake of radioactive tracer. Other diagnostic tools used to elucidate lymphangiodysplasia/lymphedema syndromes (also in newborns and children) include lymphangioscintigraphy, magnetic resonance imaging (MR lymphography and MR angiography), computed tomography (CT), CT lymphograms, 3-D oil contrast lymphography, CT-SPECT, ultrasonography, indirect lymphography, near infrared fluorescent imaging (also known as ICG lymphography) and fluorescent microlymphangiography (3). Lymphoscintigraphy is not always essential for diagnosis and one can proceed directly to molecular testing (5).
Differential diagnosis should include hereditary lymphedema; lymphedema-distichiasis; Emberger syndrome; hypotrichosis-lymphedema-telangiectasia syndrome; microcephaly with or without chorioretinopathy, lymphedema and mental retardation; lymphedema-choanal atresia; Hennekam lymphangiectasia-lymphedema syndrome; anhidrotic ectodermal dysplasia with immunodeficiency, osteopetrosis and lymphedema; congenital lipomatous overgrowth, vascular malformations and epidermal nevi syndrome; and Klippel-Trenaunay syndrome.
LMs are associated with several conditions characterized by allelic and locus heterogeneity and different modes of inheritance. Inheritance can be autosomal dominant, autosomal recessive or X-linked recessive. Genes involved in a predisposition to lymphedema triggered by surgery have also been reported (6, 7).
hereditary lymphedema 1A (LMPH1A, OMIM disease 153100) -
hereditary lymphedema 1C (LMPH1C, OMIM disease 613480) -
hereditary lymphedema 1D (LMPH1D, OMIM disease 615907) -
bilateral lymphedema of the lower limbs (OMIM disease not available) - C
lymphedema-distichiasis (OMIM disease 153400) -
primary lymphedema with myelodysplasia or Emberger syndrome (OMIM disease 614038) -
hypotrichosis-lymphedema-telangiectasia syndrome (HLTS, OMIM disease 607823) -
microcephaly with or without chorioretinopathy, lymphedema or mental retardation (MCLMR, OMIM disease 152950) -
oculodentodigital dysplasia (ODDD, OMIM disease 164200) -
nonimmune hydrops fetalis and/or atrial septal defect (HFASD, OMIM disease 617300) -
Noonan syndrome 1, 3, 4, 6, 8 (NS, OMIM disease 163950, 609942, 610733, 613224, 615355) -
Noonan-like syndrome with or without juvenile myelomonocytic leukemia (NSLL, OMIM disease 613563) -
Costello syndrome (OMIM disease 218040) -
Noonan-like syndrome with loose anagen hair (NSLH, OMIM disease 607721) -
cardiofaciocutaneous syndrome 1 (OMIM disease 115150) -
hypotrichosis-lymphedema-telangiectasia syndrome (HLTS, OMIM disease 607823) -
lymphedema-choanal atresia (OMIM disease 613611) -
Hennekam lymphangiectasia-lymphedema syndrome 1 and 2 (HKLLS1 and 2, OMIM disease 235510 and 616006) -
hereditary lymphedema 3 (LMPH3, OMIM disease 616843) -
Recently, a new form of HKLLS (HKLLS3), caused by loss-of-function mutations in
anhidrotic ectodermal dysplasia with immunodeficiency, osteopetrosis and lymphedema (OLEDAID, OMIM disease 300301
Proteus syndrome (OMIM disease 176920) caused by somatic mutations in
Pathogenic variants may include missense, nonsense, splicing, small insertions, small deletions, small indels, gross insertions, duplications and complex rearrangements.
To determine the gene defect responsible for the disease;
To confirm clinical diagnosis;
To assess the recurrence risk and perform genetic counselling for at-risk/affected individuals.
The test is listed in the Orphanet database and is offered by 22 accredited medical genetic laboratories in the EU, and in the GTR database, offered by 7 accredited medical genetic laboratories in the US.
Guidelines for clinical use of the test are described in disease-specific chapters of Genetics Home Reference (
Clinically distinguishable syndromes can be analyzed by sequencing only those genes known to be associated with that specific disease using Sanger or Next Generation Sequencing (NGS); if the results are negative, or more generally if clinical signs are ambiguous for diagnosis, a multi-gene NGS panel is used to detect nucleotide variations in coding exons and flanking introns of the above genes.
If the disorder is familial, the test is performed to identify pathogenic germline variants.
If the disease is sporadic, the first step is to identify germline variants and check the possibility of a dominant
If the test is negative or if only a single germline variant in a paradominant gene (
The test for paradominant (
Genetic analysis should be extended to relatives when the test is positive in familial cases or when a
Multiplex Ligation Probe Amplification (MLPA) is used to detect duplications and deletions in
To perform molecular diagnosis, a single sample of biological material is normally sufficient. This may be 1 ml peripheral blood in a sterile tube with 0.5 ml K3EDTA or 1 ml saliva in a sterile tube with 0.5 ml ethanol 95%. Sampling rarely has to be repeated.
A frozen intra-lesional biopsy specimen, in addition to blood or saliva, is necessary to test for somatic variations.
Gene-disease associations and the interpretation of genetic variants are rapidly developing fields. It is therefore possible that the genes mentioned in this note may change as new scientific data is acquired. It is also possible that genetic variants today defined as of “unknown or uncertain significance” may acquire clinical importance.
Identification of pathogenic variants in the above genes confirms the clinical diagnosis and is an indication for family studies.
A pathogenic variant is known to be causative for a given genetic disorder based on previous reports or predicted to be causative based on loss of protein function or expected significant damage to protein or protein/protein interactions. In this way it is possible to obtain a molecular diagnosis in new/other subjects, establish the risk of recurrence in family members and plan preventive and/or therapeutic measures.
Detection of a variant of unknown or uncertain significance (
The absence of variations in the genomic regions investigated does not exclude a clinical diagnosis but suggests the following possibilities:
Alterations that cannot be identified by sequencing, such as large rearrangements that cause loss (deletion) or gain (duplication) of extended gene fragments.
Sequence variations in genomic regions not investigated by the test, such as regulatory regions, 5’- and 3’-UTR) and deep intronic regions.
Variations in other genes not investigated by the present test.
Unexpected results may emerge from the test, for example information regarding consanguinity, absence of family correlation or other genetically-based diseases.
If the identified pathogenic variant has autosomal dominant transmission, the probability that an affected carrier transmit the disease variant to his/her children is 50% in any pregnancy, irrespective of the sex of the child conceived.
In autosomal recessive mutations, both parents are usually healthy carriers. In this case, the probability of transmitting the disorder to the offspring is 25% in any pregnancy of the couple, irrespective of the sex of the child. An affected individual generates healthy carrier sons and daughters in all cases, except in pregnancies with a healthy carrier partner. In these cases, the risk of an affected son or daughter is 50%.
In X-linked recessive inheritance, affected males transmit the pathogenic variant to their daughters and the probability that a female carrier transmit the pathogenic variant to her offspring is 50% in any pregnancy irrespective of the sex of the child conceived. Females who inherit the pathogenic variant are carriers and usually unaffected. Males who inherit the pathogenic variant are affected.
In paradominant inheritance, only the germline genetic variant is transmitted in an autosomal dominant fashion and the probability that carriers transmit the germline pathogenic variant to their children is 50% in any pregnancy, irrespective of the sex of the child conceived.
The test is limited by current scientific knowledge regarding the genes and diseases.
NGS Analytical sensitivity >99.99%, with a minimum coverage of 10X; Analytical specificity 99.99%.
SANGER Analytical sensitivity >99.99%; Analytical specificity 99.99%.
MLPA Analytical sensitivity >99.99%; Analytical specificity 99.99%.
Clinical sensitivity is estimated at about 25% (2).
Clinical specificity: data not available.
The genetic test is appropriate when:
the patient meets the diagnostic criteria for LMs;
the sensitivity of the test is greater than or equal to that of tests described in the literature.
Clinical management | Utility |
---|---|
Confirmation of clinical diagnosis | Yes |
Differential diagnosis | Yes |
Couple risk assessment | Yes |
Availability of clinical trials can be checked on-line at |